Kenneth W Wagner, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA00865 Issued in TX

Practice address

17115 Red Oak Dr
Suite 211
Houston, TX 77090-2641

Phone

(281) 719-9681

Fax

(281) 791-0059

NPI assigned

Jul 18, 2006

Last updated

Apr 29, 2021By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 3

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: kennethw.wagner@direct.memorialhermann.org
• Direct secure messaging: kennethw.wagner@memorialhermann.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Ess of Dalhart LLC

  • Emergency Medicine Physician
  • Dalhart, TX
  • NPI 1154899425
  NPD
• Orthopaedic Associates, LLP

  • Orthopaedic Surgery Physician
  • Houston, TX
  • NPI 1841276631
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153180800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1619654400000",
    "number": "1700804309",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17070 RED OAK DR",
            "address_2": "STE 507",
            "city": "HOUSTON",
            "state": "TX",
            "postal_code": "770902617",
            "telephone_number": "281-719-9681",
            "fax_number": "281-791-0059"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17115 RED OAK DR",
            "address_2": "SUITE 211",
            "city": "HOUSTON",
            "state": "TX",
            "postal_code": "770902641",
            "telephone_number": "281-719-9681",
            "fax_number": "281-791-0059"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "KENNETH",
        "middle_name": "W",
        "name_prefix": "Mr.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-18",
        "last_updated": "2021-04-29",
        "certification_date": "2021-04-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "TX",
            "license": "PA00865",
            "primary": true
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "TX",
            "license": "PA00865",
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "87N250",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "198928701",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBSTX",
            "identifier": "8Y8598",
            "state": "TX"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "KennethW.Wagner@memorialhermann.org",
            "affiliation": "Y",
            "affiliationName": "Memorial Hermann Medical Group",
            "address_1": "909 Frostwood Dr.",
            "address_2": "Suite 1.100",
            "city": "Houston",
            "state": "TX",
            "country_code": "US",
            "postal_code": "770242301",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Crystal Wagner
• Haley McKenna Wagner, NP
• Holden Wagner, MD
• Jamie Lynn Wagner, D.O.
• Jennifer Wagner, PHARMD
• Kevin Wagner, PH.D.
• Lisa Donette Wagner, LMSW
• Makaylah Wagner
• Sarah Wagner, RD, MPH
• Shondi Wagner

• Physician Assistant in Houston, TX
• Providers in Houston, TX by specialty
• Physician Assistant in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 29, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.